Ixekizumab best immunodulator therapy for nail psoriasis: JAAD study

Ixekizumab shows best efficacy immunodulator therapy for nail psoriasis : Study published in Journal of American academy of dermatology

Psoriasis is a chronic inflammatory disease that primarily affects the skin and joints with incidence of approximately 1.02% in India. Nail psoriasis is seen in nearly 50% of patients with cutaneous disease.

Both topical and systemic treatments have been used in management. Topical treatment has a major limitation of poor penetration through the nail or its matrix. Biologicals like TNF-alpha inhibitors, anti IL-12/23, anti IL-23,and anti IL-17-A antibodies and small molecule inhibitors like oral phosphodiesterase 4 inhibitor and Janus kinase inhibitors are important systemic drugs in the armamentarium of dermatologist to treat nail psoriasis.

A systematic review and network meta-analysis (NMA) was done by Huang et al in JAAD to compare the treatment efficacy of small molecule inhibitors and biologics for patients with nail psoriasis and to identify which are most effective.

The researchers investigated the efficacy of these drugs compared to placebo for patients with nail psoriasis. The primary outcome was the percent change in any nail scores regarding clinical signs, such as the most common Nail Psoriasis Severity Index (NAPSI). The secondary

outcome was the event rate of 50%, 75%, and 100% improvement of nail psoriasis severity index (NAPSI 50/75/100, respectively).

Eligible studies in online databases were identified until March 10, 2020. Surface under the cumulative ranking curve (SUCRA) of improvement in nail score at 10 to 16 and at 24 to 26 weeks, as well as 100% improvement of Nail Psoriasis Severity Index (NAPSI), were performed.

Results

Thirty-nine studies involving 15,673 patients with nail psoriasis were included.

• Nail score improvement at 10 to 16 weeks

According to the surface under the cumulative ranking curve tofacitinib was ranked best, followed by infliximab.

• Nail score improvement at 24 to 26 weeks

The percentage of nail score improvement for all treatments were significantly superior to placebo. According to the Surface under the cumulative ranking curve, ixekizumab was ranked the best, followed by infliximab.

• NAPSI 50/75/100 at 24 to 26 weeks

All treatments except ustekinumab attained significantly greater improvement than placebo. Ixekizumab (OR, 2.98; 95% CI, 1.75-5.10) was ranked the best followed by adalimumab.

In this analysis all immunosuppressive agents were shown to significantly improve nail score compared with placebo in 10 to 16 weeks and 24 to 26 weeks.

Studies for tofacitinib were having low evidence and dose of tofacitinib 10 mg twice daily, used in the studies is higher than the dosage suggested by the US Food and Drug Administration. With an ongoing safety trial showing an increased risk of blood clots and death, tofacitinib 10 mg twice daily can be risky.

In both 10 to 16 and 24 to 26 weeks of treatment, infliximab followed by adalimumab achieved better nail score improvement among the group of TNF-alpha inhibitors.

Nails share an anatomic association with ligaments of nearby joints. Distal interphalangeal joint arthritis and nail psoriasis are considerably connected. Therefore, a more efficacious drug for psoriatic arthritis might also be a better treatment for nail psoriasis.

A reasonable duration of treatment before the assessment of clinical improvement should be 4-6 months based on nail growth pattern. For tofacitinib longer-term follow-up are warranted to confirm its effect on nail psoriasis.

In conclusion with the present evidence, ixekizumab may currently be the best clinical option for nail psoriasis.

Source- Huang IH, Wu PC, Yang TH, Li H, Huang YT, Cheng YC, Kuo PH, Lee YH, Huang YC, Tu YK. Small molecule inhibitors and biologics in treating nail psoriasis: A systematic review and network meta-analysis. J Am Acad Dermatol. 2021 Jul;85(1):135-143. doi: 10.1016/j.jaad.2021.01.024. Epub 2021 Jan 19. PMID: 33482253.